ADRENOCORTICAL INSUFFICIENCY

[Addison’s Disease]

ANATOMY AND PHYSIOLOGY

Adrenal Glands

The adrenal glands are small vital endocrine

structures that rest upon the upper end of each
kidney. Each adrenal gland is composed of an inner
core, the medulla and an outer shell, the cortex.

The inner portion, the medulla produces the

catecholamines epinephrine and norepinephrine.
The much larger outer adrenal portion, the cortex
has three zones. The outermost zone, the zona
glomerulosa, produces mineralocorticoids, primarily
aldosterone. The zona fasciculata, the middle and
largest zone, produces the glucocorticoids cortisol (hydrocortisone), cortisone, and
corticosterone as well as small amounts of sex hormones androgen and estrogen. The inner
zone, the zona reticularis, produces mainly glucocorticoids and some sex hormones.

The three (3) classes of steroid hormones produced by the adrenal cortex are all
synthesized from cholesterol. These could be easily
remembered by representing the 3 functions of the
hormones of the adrenal cortex by the letter “S”, as salt,
sugar, and sex.

Mineralocorticoids (primarily aldosterone) regulate

electrolyte balance by promoting sodium retention and
potassium excretion. These physiologic activities, in turn,
help sustain normal BP and cardiac output.
 Cortisol is the major glucocorticoid that has effects on glucose (increases blood glucose
level) and protein (tissue wasting) metabolism, on fluid and electrolyte balance (increases
sodium retention and potassium excretion), in inflammation and immunity (suppresses the
inflammatory response to tissue injury and the protective immune response to invasion by
infectious agents), and on stress (decreases resistance to stress).

Because cortisol is so vital to health, the amount of cortisol produced by the adrenals is
precisely balanced. Like many other hormones, cortisol is regulated by the brain's hypothalamus
and the pituitary gland. First, the hypothalamus sends "releasing hormones" to the pituitary
gland. The pituitary responds by secreting other hormones that regulate growth, thyroid and
adrenal function, and sex hormones such as estrogen and testosterone. One of the pituitary's
main functions is to secrete ACTH (adrenocorticotropin), a hormone that stimulates the adrenal
glands. When the adrenals receive the pituitary's signal in the form of ACTH, they respond by
producing cortisol. Completing the cycle, cortisol then signals the pituitary to lower secretion of
ACTH.

DESCRIPTION
  The disease is named for its discoverer, Dr. Thomas Addison, a British surgeon who described
adrenal insufficiency in 1849, though endocrine functions had yet to be explained.
 It is a condition where the adrenal cortex (the outer layer of the adrenal gland that
produces mineralocorticoids, glucocorticoids, and androgens) is progressively
destroyed, resulting in decreased secretions of the hormones.

Other names
 Adrenal Insufficiency
 Adrenocortical Hypofunction
 Hypocortisolism
 Primary Adrenocortical Insufficiency
 Chronic Adrenal Insufficiency
 Chronic Primary Adrenal Insufficiency

Clinical Manifestations
The onset of Addison's disease is usually insidious. The client experiences mild fatigue,
languor, irritability, weight loss, nausea/vomiting, and postural hypotension weeks or months
before diagnosis of the disease. As the disorder progresses, manifestations intensify. The
development of clinical manifestations of adrenocortical insufficiency requires the loss of over
90% of both adrenal cortices.

HOR FUNCTION ADDISON’S DISEASE

MONE
Aldosterone Promotes retention of More than 90% of adrenal gland is destroyed before the
sodium (and water) in clinical picture of adrenal insufficiency emerges.
kidney Increased secretion of sodium and water influences
dehydration, hyponatremia, orthostatic hypotension,
decreased urine output, decreased cardiac output, weight
loss, salt craving, acidosis, circulatory collapse and shock
Cortisol Promotes Decreased gluconeogenesis causes depleted liver glycogen
gluconeogenesis stores manifested by hypoglycemia, weakness, fatigue
anorexia, weight loss, vomiting, mental confusion, emotional
Maintains plasma disturbances (mild neurosis to depression)
glucose level

Promotes appetite
Causes release of Inadequate release of epinephrine produces hypoglycemia
epinephrine from and hypotension
adrenal medulla
Assists in adaptation to Lowers resistance to stress and produces a “hyperresponse “
stress by increased to stressors: hypoglycemia, hypotension, hyperthermia
gluconeogenesis
releasing an anti
 inflammatory response;
augmenting release of
catecholamines to
increase BP
ACTH regulates melanocyte Stimulates an increase MSH: increases skin and mucous
stimulating hormone membrane pigmentation, especially fingers, toes and sun
exposed body parts (skin appears bronzed)
Androgens Female oligomenorrhea or amenorrhea, decrease in body hair
Male No manifestations in males because testes produce adequate
quantities of sex hormones

In some cases, Addison's symptoms may present rapidly. This "acute adrenal failure" is
known as an Addisonian crisis (an exaggerated state of adrenal cortical insufficiency). An illness
or accident can aggravate the adrenal problems causing the Addisonian crisis, although the
most common cause is abrupt discontinuation of corticosteroid therapy without tapering the
dose. It may be provoked by physical stress, such as an injury, infection or illness.
An addisonian crisis is a life-threatening situation that results in low blood pressure, low
blood levels of sugar and high blood levels of potassium. This situation requires immediate
medical care and can be fatal if not treated quickly.

Types/Kinds/Variants
Epidemiology
Etiology
Pathophysiology

Autoimmune disorder, Surgical removal

Cortecosteroid and Idiopathic atrophy, TB Inadequate
of adrenal
sudden cessation of and histoplasmosis secretion of ACTH
glands
exogenous from the pituitary
adrenocortical gland
hormonal therapy

Inadequate adrenal cortex function

Adrenocortical Insufficiency
Signs& Symptoms